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Some people in states of excited delirium die while in police custody. Emerging evidence suggests that physical restraint in certain positions may contribute to such deaths. In this study the authors determined the frequency of physical restraint among people in a state of excited delirium who died unexpectedly.The authors reviewed the records of 21 cases of unexpected death in people with excited delirium, which were investigated by the Office of the Chief Coroner for Ontario between 1988 and 1995. Eyewitness testimony, findings during postmortem examinations, clinical history, toxicological data and other official documents describing the events surrounding the deaths were analysed. Specific reference was made to documented eyewitness testimony of restraint method, body position and use of capsicum oleoresin (pepper) spray. Because cocaine was detected in the blood of some of these people during the postmortem examination, the role of cocaine in excited delirium was examined by comparing the cocaine levels in these cases with levels in 2 control groups: 19 people who died from acute cocaine intoxication and 21 people who had used cocaine shortly before they died but who had died from other causes.In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained. The excited delirium was caused by a psychiatric disorder in 12 people (57%) and by cocaine-induced psychosis in 8 (38%). Eighteen people (86%) were in police custody when they died. Four (19%) had been sprayed with capsicum oleoresin, and heart disease was found in another 4 at autopsy. The blood level of cocaine in those whose excited delirium was cocaine induced was similar to levels found in recreational cocaine users and lower than levels found in people who died from cocaine intoxication.Restraint may contribute to the death of people in states of excited delirium, and further studies to test this hypothesis are recommended. Meanwhile, law enforcement authorities and others should bear in mind the potential for the unexpected death of people in states of excited delirium who are restrained in the prone position or with a neck hold.